<form action="https://ssl.dotpay.pl/" method="post">

	<input type=hidden name="id" value="28762">
	<input type=hidden name="lang" value="pl">
	<!-- dostępne wersje językowe: pl, en, de -->
	
	<input type="hidden" name="type" value="3">
	<input type="hidden" name="buttontext" value="Powrót do serwisu {$smarty.const.HTTP_URL}...">
	<!-- sposob powrotu uzytkownika do serwisu -->
	
	<input type=hidden name="URL" value="{$smarty.const.HTTP_URL}{$smarty.request.page}.html">
	<!-- adres na ktory zostanie przekierowany uzytkownik po dokonaniu platnosci -->
	
	<input type=hidden name="URLC" value="{$smarty.const.HTTP_URL}potwierdzenie,Platnosci,DotPay.html">
	<!-- adres na ktory zostanie wyslane potwierdzenie -->

	<table border="0" cellpadding="0" cellspacing="0" id="glowna">
		<tr>
			<th>
				Tytułem:
			</th>
			<td>
				<textarea cols="30" rows="5" name="opis" readonly>{$tranzakacja.plTresc}</textarea>
			</td>
        </tr>
		<tr>
			<th>
				Kwota:
			</th>
			<td>
				<input type="text" name="kwota" size="15" value="{$tranzakacja.plCena|default:'99.00'}" readonly />
					<select name="waluta">
						<option selected>PLN</option>
						<option>EUR</option>
						<option>USD</option>
					</select>
			</td>
		</tr>
	    
		<tr>
			<th>
				Wybierz formę płatności:
			</th>
			<td>
                                 <input type="radio" value="0" name="kanal"> Karta VISA, MasterCard, EuroCard, JCB, Diners Club<br>
                                 <input type="radio" value="1" name="kanal"> mTransfer<br>
                                 <input type="radio" value="2" name="kanal"> Płacę z Inteligo<br>
                                 <input type="radio" value="3" name="kanal"> Multitransfer<br>
                                 <input type="radio" value="6" name="kanal"> Przelew24 (BZWBK)<br>
                                 <input type="radio" value="7" name="kanal"> ING Bank Śląski "ING Online"<br>
                                 <input type="radio" value="8" name="kanal"> Bank BPH "Sezam"<br>
                                 <input type="radio" value="9" name="kanal"> Pekao24 (Bank Pekao S.A.)<br>
                                 <input type="radio" value="10" name="kanal"> Bank Millenium "Millenet"<br>
                                 <input type="radio" value="11" name="kanal"> Przelew lub przekaz pocztowy<br>
                                 <input type="radio" value="13" name="kanal"> Deutsche Bank PBC S.A.<br>
                                 <input type="radio" value="14" name="kanal"> Kredyt Bank S.A. (KB24)<br>
                                 <input type="radio" value="15" name="kanal"> Inteligo (Bank PKO BP)<br>
                                 <input type="radio" value="16" name="kanal"> Lukas Bank<br>
                                 <input type="radio" value="17" name="kanal"> Nordea Bank Polska<br>
                                 <input type="radio" value="18" name="kanal"> Bank BPH – usługa „Przelew z BPH”<br>
                                 <input type="radio" value="19" name="kanal"> Citibank Handlowy<br>
                                 <input type="radio" value="21" name="kanal"> Dotpay Moje Rachunki<br>
                                 <input type="radio" value="22" name="kanal"> Ukash<br>
                                 <input type="radio" value="23" name="kanal"> Moneybookers<br>
                                 <input type="radio" value="24" name="kanal"> mPay<br>
                                 <input type="radio" value="25" name="kanal"> Invest Bank<br>
                                 <input type="radio" value="26" name="kanal"> Bank Ochrony Środowiska<br>
                                 <input type="radio" value="27" name="kanal"> Bank Gospodarki Żywnościowej<br>
                                 <input type="radio" value="31" name="kanal"> Zielone Okienko (Płatnośd w sklepach Żabka)<br>
                                 <input type="radio" value="32" name="kanal"> Fortis Bank S.A.<br>
                                 <input type="radio" value="33" name="kanal"> Volkswagen Bank Polska S.A.<br>
    
			</td>
		</tr>
		<tr>
			<th>
				imię:
			</th>
			<td>
				<input class="in" type="text" name="forename" value="{$platnik.imie}">
			</td>
		</tr>
		<tr>
			<th>
				nazwisko:
			</th>
			<td>
				<input class="in" type="text" name="surname" value="{$platnik.nazwisko}">
			</td>
		</tr>
		<tr>
			<th>
				ulica:
			</th>
			<td>
				<input class="in" type="text" name="street" value="{$platnik.adres}">
			</td>
		</tr>
		<tr>
			<th>
				numer domu:
			</th>
			<td>
				<input class="in" type="text" name="street_n1" value="">
			</td>
		</tr>
		<tr>
			<th>
				numer mieszkania:
			</th>
			<td>
				<input class="in" type="text" name="street_n2" value="">
			</td>
		</tr>
		<tr>
			<th>
				miejscowość:
			</th>
			<td>
				<input class="in" type="text" name="city" value="{$platnik.miasto}">
			</td>
		</tr>
		<tr>
			<th>
				kod pocztowy:
			</th>
			<td>
				<input class="in" type="text" name="postcode" value="{$platnik.kodpocztowy}" readonly>
			</td>
		</tr>
		<tr>
			<th>
				kraj:
			</th>
			<td>
				<select name="country">
					<option VALUE="DZA" >Algeria</option>
					<option VALUE="AND" >Andorra</option>
					<option VALUE="AIA" >Anguilla</option>
					<option VALUE="ATG" >Antigua</option>
					<option VALUE="ARG" >Argentina</option>
					<option VALUE="ARM" >Armenia</option>
					<option VALUE="ABW" >Aruba</option>
					<option VALUE="AUS" >Australia</option>
					
					<option VALUE="AUT" >Austria</option>
					<option VALUE="AZE" >Azebaijan</option>
					<option VALUE="BHS" >Bahamas</option>
					<option VALUE="BHR" >Bahrain</option>
					<option VALUE="BGD" >Bangladesh</option>
					<option VALUE="BRB" >Barbados</option>
					<option VALUE="BLR" >Belarus</option>
					<option VALUE="BEL" >Belgium</option>
					<option VALUE="BLZ" >Belize</option>
					
					<option VALUE="BMU" >Bermuda</option>
					<option VALUE="BOL" >Bolivia</option>
					<option VALUE="BWA" >Botswana</option>
					<option VALUE="BRA" >Brazil</option>
					<option VALUE="SLB" >British Solomon Islands</option>
					<option VALUE="BRN" >Brunei</option>
					<option VALUE="BGR" >Bulgaria</option>
					<option VALUE="CAN" >Canada</option>
					<option VALUE="CYM" >Cayman Islands</option>
					
					<option VALUE="CHL" >Chile</option>
					<option VALUE="CHN" >China</option>
					<option VALUE="COL" >Colombia</option>
					<option VALUE="CRI" >Costa Rica</option>
					<option VALUE="HRV" >Croatia</option>
					<option VALUE="CYP" >Cyrus</option>
					<option VALUE="CZE" >Czech Republic</option>
					<option VALUE="DNK" >Denmark</option>
					<option VALUE="DMA" >Dominica</option>
					
					<option VALUE="DOM" >Dominican Republic</option>
					<option VALUE="ECU" >Ecuador</option>
					<option VALUE="EGY" >Egypt</option>
					<option VALUE="SLV" >El Salvador</option>
					<option VALUE="EST" >Estonia</option>
					<option VALUE="FJI" >Fiji</option>
					<option VALUE="FIN" >Finland</option>
					<option VALUE="FRA" >France</option>
					<option VALUE="PYF" >French Polynesia</option>
					
					<option VALUE="DEU" >Germany</option>
					<option VALUE="GHA" >Ghana</option>
					<option VALUE="GRC" >Greece</option>
					<option VALUE="GUM" >Guam</option>
					<option VALUE="GTM" >Guatemal</option>
					<option VALUE="GUY" >Guyana</option>
					<option VALUE="HTI" >Haiti</option>
					<option VALUE="HND" >Honduras</option>
					<option VALUE="HKG" >Hong-Kong</option>
					
					<option VALUE="HUN" >Hungary</option>
					<option VALUE="ISL" >Iceland</option>
					<option VALUE="IND" >India</option>
					<option VALUE="IDN" >Indonesia</option>
					<option VALUE="IRN" >Iran</option>
					<option VALUE="IRL" >Ireland</option>
					<option VALUE="ISR" >Israel</option>
					<option VALUE="ITA" >Italy</option>
					<option VALUE="JAM" >Jamaica</option>
					
					<option VALUE="JPN" >Japan</option>
					<option VALUE="JOR" >Jordan</option>
					<option VALUE="KAZ" >Kazakhstan</option>
					<option VALUE="KEN" >Kenya</option>
					<option VALUE="KOR" >Korea</option>
					<option VALUE="KWT" >Kuwait</option>
					<option VALUE="LVA" >Latvia</option>
					<option VALUE="LBN" >Lebanon</option>
					<option VALUE="LTU" >Lithuania</option>
					
					<option VALUE="LUX" >Luxembourg</option>
					<option VALUE="MAC" >Macao</option>
					<option VALUE="MKD" >Macedonia</option>
					<option VALUE="MDG" >Madagascar</option>
					<option VALUE="MYS" >Malaysia</option>
					<option VALUE="MLT" >Malta</option>
					<option VALUE="MUS" >Mauritius</option>
					<option VALUE="MEX" >Mexico</option>
					<option VALUE="MAR" >Morocco</option>
					
					<option VALUE="MOZ" >Mozambique</option>
					<option VALUE="NAM" >Namibia</option>
					<option VALUE="NPL" >Nepal</option>
					<option VALUE="NDL" >Netherlands</option>
					<option VALUE="ANT" >Netherlands Antiles</option>
					<option VALUE="NZL" >NewZeland</option>
					<option VALUE="NIC" >Nicaragua</option>
					<option VALUE="NGA" >Nigeria</option>
					<option VALUE="NOR" >Norway</option>
					
					<option VALUE="OMN" >Oman</option>
					<option VALUE="PAK" >Pakistan</option>
					<option VALUE="PAN" >Panama</option>
					<option VALUE="PNG" >Papua New Guinea</option>
					<option VALUE="PRY" >Paraguay</option>
					<option VALUE="PER" >Peru</option>
					<option VALUE="PHL" >Philippines</option>
					<option VALUE="POL" selected>Polska</option>
					<option VALUE="PRT" >Portugal</option>
					
					<option VALUE="QAT" >Qatar</option>
					<option VALUE="ROM" >Romania</option>
					<option VALUE="RUS" >Russia</option>
					<option VALUE="WSM" >Samoa</option>
					<option VALUE="SAU" >SaudiArabia</option>
					<option VALUE="SEN" >Senegal</option>
					<option VALUE="SYC" >Seychelles</option>
					<option VALUE="SLE" >Sierra Leone</option>
					<option VALUE="SGP" >Singapore</option>
					
					<option VALUE="SVK" >Slovakia</option>
					<option VALUE="SVN" >Slovenia</option>
					<option VALUE="ZAF" >South Africa</option>
					<option VALUE="ESP" >Spain</option>
					<option VALUE="LKA" >Sri Lanka</option>
					<option VALUE="KNA" >St.Kitts-Nevis-Anguilla</option>
					<option VALUE="LCA" >St.Lucia</option>
					<option VALUE="SAN" >St.Martin</option>
					<option VALUE="VCT" >St.Vincent</option>
					
					<option VALUE="SUR" >Suriname</option>
					<option VALUE="SWE" >Sweden</option>
					<option VALUE="CHE" >Switzerland</option>
					<option VALUE="TWN" >Taiwan</option>
					<option VALUE="THA" >Thailand</option>
					<option VALUE="TON" >Tonga</option>
					<option VALUE="TTO" >Trinidad And Tobago</option>
					<option VALUE="TUN" >Tunisia</option>
					<option VALUE="TUR" >Turkey</option>
					
					<option VALUE="TCA" >Turks And Caicos Island</option>
					<option VALUE="UKR" >Ukrainian</option>
					<option VALUE="ARE" >United Arab Emirates</option>
					<option VALUE="GBR" >United Kingdom</option>
					<option VALUE="USA" >United States Of America</option>
					<option VALUE="URY" >Uruguay</option>
					<option VALUE="UZB" >Uzbekistan</option>
					<option VALUE="VEN" >Venezuela</option>
					<option VALUE="VNM" >Vietnam</option>
					
					<option VALUE="ZWE" >Zimbabwe</option>
				</select>
			</td>
		</tr>
		<tr>
			<th>
				adres email:
			</th>
			<td>
				<input class="in" type="text" name="email" value="{$platnik.email}" readonly>
			</td>
		</tr>
		<tr>
			<th>
				numer telefonu:
			</th>
			<td>
				<input class="in" type="text" name="phone" value="{$platnik.telefon}">
			</td>
		</tr>
		<tr>
			<th colspan="2">
				<input type="submit" value="Zapłać przez Dotpay">
			</th>
		</tr>
 </table>
</form>
